HomeMy WebLinkAbout4210 Breakwater Ct - Applications/Gas - Log, Line, Pipe - 06/04/2012JUN-04-2012(MON) 10:29 P.001/001.
1
City of Planning, Development & Transportation
Fit Collins For N. College Ave P.O, Box 580
Fort Collins, CO 60524
Phone 970.416-2740 Fax 224-6134
OVER-THE-COUNTER PERMITS ONLY
This application is to be used to apply for the following permits only (chock all that apply). Air iticning
Demolition (interior non-structural) Electrical Alteration (not service change) Gas Lighter 'Gas Log
Heating Unit. Lawn Sprinkler Mobile Home replacement Roofing Sewer Llne Photo -voltaic
Ventilation Water'Heater Water Line WoodlPellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all avDlie (tie information on the application. Incomplete applications will not be accepted.
Application # 01. dS Date 0L} �U� • (p� ��
For ofee use only c•�
]ob SiCe "" '
Applicant
Contractor City of Ft Collins Sales Tax ak
Salrxf rnranberiSMU#Vdbyaflarmrracrom
Address
Address
Value qP ConStnJ omaterials, pront)
Zip Phone
City/State Zip Phone
awstate Zip Phone
Are you paying taxes here or by report? Here Report
Are you paying with your trust account? Yes No
I, this a residential or corn ercial project? esrdenda Commercial
If residential, is IC Detae ndo/townhome (single family attached) Duplex
Multifamily (apartment) Garage
if commerdal, Is It: Bank Bar Church Hotel/Motel Medical office Office Retail
Restaurant Other (explain)
is this building SO years of age or more? Yes No Ifyes ypuMay need to=tactH/smdeF'wervatron
If this Is for a demolition permit, what year was the bullding constructed?
!f prlgr to t97S, you will need an asbrsms a e ment to submit w/th this applrraN017.
of
*If lawn sprinkler/backnow preventer, must list licensed plumber. If flrst•klme Alt:, must list Ilunsed electrician.
Sub ran tractors: 4&r the company name or pry of fr Callin5lltensr r
Elecn Iden��_. Plumber--.....,� Mrchanical
. Wtafer Other"
I hereby acknowledge that I have read this appllcatlon and S12te that the above Information is complete and correct. I agree to
comply with all requirements contained herein and city ordinances and state laws regulating building construction. I know that a
Permit is not valid until It has been paid and Issued.
Applicant -
Print Ndme=: elnSQ
Signatu ,
Date _`